Download Departments Release New Guidance on Required

November 3, 2015
Departments Release New Guidance on
Required Preventive Services Under the
Affordable Care Act
1
The Affordable Care Act requires non-grandfathered health plans to provide
certain preventive services in network without charge to the participant or
2
beneficiary. On October 23, 2015, the Departments of Labor, Treasury, and
Health and Human Services (the “Departments”), which are responsible for
implementing group health plan standards under the Affordable Care Act,
published a series of answers to Frequently Asked Questions (FAQs) clarifying
3
certain issues. This Update summarizes these new answers to FAQs.
Background
The preventive services that must be provided without cost sharing fall into four
different categories: services with an “A” or “B” recommendation from the U.S.
Preventive Services Task Force (USPSTF), vaccines recommended by the
Centers for Disease Control and Prevention (CDC), the Bright Futures
guidelines developed by the American Academy of Pediatrics with support
from the Health Resources and Services Administration (HRSA), and certain
women’s services listed in HRSA guidelines (supplementing some of the
USPSTF recommendations).
Health
Compliance
News Highlights:
• The latest answers to FAQs
provide new guidelines for
how non-grandfathered plans
pay for preventive services.
• Sponsors of those plans
should review both plan
documents and plan
operations to assure that
they are in compliance with
the latest guidelines.
• Failure to properly implement
a non-grandfathered benefit
could lead to tax penalties.
Lactation Counseling and Equipment
The HRSA guidelines mentioned above require plans to provide coverage of
comprehensive lactation support, counseling and equipment rental. Lactation support
generally helps mothers learn how to feed babies and address the medical problems
that may arise. The new answers to FAQs clarify several issues relating to these
requirements:
• Plans must provide a list of lactation counseling providers who are in the
plan’s network. If the plan does not include such counselors in its network,
the plan must cover this service without cost sharing when provided by out-ofnetwork providers.
• Women who live in states that do not license lactation counselors must still be able to
receive these services. Subject to reasonable medical-management techniques,
1
The Affordable Care Act is the shorthand name for the Patient Protection and Affordable Care Act
(PPACA), Public Law No. 111-48, as modified by the subsequently enacted Health Care and Education
Reconciliation Act (HCERA), Public Law No. 111-152.
2
For background on the preventive services requirements, see Segal Consulting’s March 12, 2013 Capital
Checkup, “New Guidelines on Preventive Care Benefits for Non-Grandfathered Plans.”
3
These answers to FAQs are available on the DOL website. For information on previous recent answers to
FAQs on required preventive services (addressing some of the same topics), see Segal’s May 28, 2015
Update, “Additional Coverage Required for Preventive Services Under the Affordable Care Act.”
Segal Consulting
lactation counseling must be covered without cost sharing when performed by any
provider acting within the scope of his or her license or certification under applicable
state laws (e.g., registered nurses).
• Plans cannot limit lactation counseling to inpatient settings.
• Plans cannot require that lactation equipment be obtained within a specific time
frame (e.g., within six months of delivery). The requirement to provide these services
extends for the duration of breastfeeding.
• All health plan sponsors must provide a Summary of Benefits and Coverage
(SBC) that includes an Internet address or other contact information, for
obtaining a list of network providers.
Weight Management for Adult Obesity
Non-grandfathered plans are not permitted to have a general exclusion for weightmanagement services for obese adults that would encompass required preventive
services. However, precisely what services plans must offer without cost sharing is not
clear. Plans must cover screening for obesity for adults. In addition, the USPSTF
recommends intensive, multicomponent behavioral interventions for adults with a
2
body mass index of 30 kg/m or higher.
While plan sponsors are permitted to use reasonable medical-management
techniques to determine the frequency, method, treatment or setting for these
interventions, the Departments set out this example of an intensive,
multicomponent behavioral intervention for weight management:
• Group and individual sessions of high intensity (12 to 26 sessions in a year),
• Behavioral-management activities, such as weight-loss goals,
• Improving diet or nutrition and increasing physical activity,
• Addressing barriers to change,
• Self-monitoring, and
• Strategizing how to maintain lifestyle changes.
Screening Colonoscopy
A screening colonoscopy must be covered without cost sharing. However, certain
services are integral to receiving the colonoscopy. Consequently, non-grandfathered
plans may not charge cost sharing for the following:
• A required specialist consultation prior to the colonoscopy, if the attending provider
determines that the pre-procedure consultation would be medically appropriate for
the individual, or
• A pathology exam on a polyp biopsy when provided in connection with a screening colonoscopy.
Update Page 2
Segal Consulting
This guidance is effective for plan years beginning on or after December 22, 2015
(January 1, 2016 for calendar-year plans). Previous guidance had clarified that
anesthesia services related to the screening colonoscopy must be covered without
4
cost sharing.
Testing for Breast Cancer Genes
Women found to be at increased risk using a screening tool designed to identify a
family history that may be associated with an increased risk of having a potentially
harmful gene mutation must receive, without cost sharing, coverage for genetic
5
counseling, and, if indicated, testing for mutations of BRCA genes. This requirement
also applies to a woman previously diagnosed with cancer, as long as she is not
currently symptomatic or being treated for breast, ovarian, tubal or peritoneal cancer.
Implications for Plan Sponsors
Sponsors of non-grandfathered plans should review both plan documents and plan
operations to assure that they are in compliance with the latest answers to FAQs. With
respect to weight-management counseling, plan sponsors may want to develop custom
programs with discounted provider network services, clear clinical management rules,
and protocols and reporting tools to make sure care is appropriate and help manage
costs. In addition to implementing the preventive services benefits operationally, it is
important to have documentation of the benefit, both so that plan participants can
understand their coverage and that the plan sponsor can demonstrate the benefit if
audited by the Department of Labor or Centers for Medicare & Medicaid Services.
Failure to properly implement a non-grandfathered benefit could lead to excise tax
penalties of $100 per day for each affected individual and/or the imposition of a
requirement to re-process claims under the correct standards.
_______________________________
4
That guidance is summarized in Segal’s May 28, 2015 Update, “Additional Coverage Required for
Preventive Services Under the Affordable Care Act.”
5
BRCA is an abbreviation derived from the first two letters of the words "breast cancer". The BRCA 1 and
BRCA 2 gene mutations are associated with an increased risk of breast and ovarian cancer.
Update is Segal Consulting’s electronic newsletter summarizing compliance news. Update is for
informational purposes only and should not be construed as legal advice. It is not intended to provide
guidance on current laws or pending legislation. On all issues involving the interpretation or application
of laws and regulations, plan sponsors should rely on their attorneys for legal advice.
If you would like additional information about this news, please contact your Segal
consultant or the Segal office nearest you. Segal can be retained to work with plan
sponsors and their legal counsel on compliance issues.
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Copyright © 2015 by The Segal Group, Inc. All rights reserved.
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